Calcium and Bone

Who to refer:

Patients with biochemical abnormalities of calcium, PTH and vitamin D

• Eg Hypercalcaemia provided the cause is not obviously malignant, renal or gastrointestinal.  A suppressed PTH would suggest a non-endocrine cause of hypercalcaemia. A raised or high/normal PTH in the context of hypercalcaemia would be suggestive of hyperparathyroidism and should be referred to endocrinology. If the patient is frail/elderly and you think that they are unlikely to be suitable for referral for parathyroidectomy please consider sending in a referral as ‘Advice Only’ on SCI Gateway. Where appropriate, we are happy to provide advice without bringing the patient up to clinic.
• Patients with hypoparathyroidism should be referred to endocrinology (Low PTH, low Ca, low/normal 25(OH)D, low 1,25(OH)D, high PO4, normal AlkP – particularly in patients with history of neck surgery).
• Those with severe hypocalcaemia (Ca2+ usually <1.9mmol/l with muscle twitches, convulsions, Chvostek’s sign, Trousseau’s sign, carpal spasm, papilloedema, prolonged QT interval on ECG) or hypomagnesaemia, who may need iv replacement
• Most patients with vitamin D deficiency can be managed in the community (see ‘Who not to refer’ below).  However, if patients have significant bone pain or do not respond to vitamin D replacement as expected, referral/discussion with endocrinology would be appropriate.  Patients with low vitamin D, raised PTH and RAISED calcium should also be referred as they may have concomitant primary hyperparathyroidism, in which case vitamin D treatment will probably cause Ca2+ levels to rise further.
• Patients with renal failure (eGFR <45) who may need ‘activated’ vitamin D, or lower doses of vitamin D, should be discussed with the renal team by contacting: rierenaladvice@luht.scot.nhs.uk Patients with GI disorders who may require high doses or parenteral administration of vitamin D should be discussed with GI.  In general, if you are unsure whether patients meet referral criteria, please use the ‘Advice only’ option on SCI Gateway

 Osteoporosis secondary to endocrine disease e.g.

• Hypogonadism
• Hyperparathyroidism
• Cushing’s syndrome
• Uncontrolled thyrotoxicosis

Who not to refer:

Uncomplicated Vitamin D deficiency without other biochemical abnormalities.

25(OH) vitamin D level <25 nmol/l, which is indicative of Vitamin D deficiency  If vitamin D deficiency is uncomplicated (eg no other associated biochemical abnormalities or only modest elevations of ALP and PTH), it is usually appropriate to manage the patient in primary care. Please see advice on Vitamin D in adults.

Hypercalcaemia and known malignancy

Refer to oncology

Low/normal calcium and elevated PTH

This is suggestive of secondary hyperparathyroidism in response to low calcium and the cause of low calcium should be sought to guide appropriate referral (eg malabsorption to GI, renal impairment to nephrology). 

Osteoporosis with no known underlying endocrine condition

Refer to rheumatology

It is usually appropriate to manage uncomplicated vitamin D deficiency in primary care.  Please see advice on Vitamin D in adults.

There is a separate link to guidance for the management of Vitamin D Deficiency in children and young people.